- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,832.64 / $3,832.64 / $9,855.36
| Facility | | $3,832.64 | $3,832.64 | $9,855.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,832.64 / $3,832.64 / $5,146.68
| Professional | | $3,832.64 | $3,832.64 | $5,146.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,241.54 / $11,032.53 / $12,319.20
| Professional | | $8,241.54 | $11,032.53 | $12,319.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,291.23 / $6,291.23 / $9,235.81
| Professional | | $6,291.23 | $6,291.23 | $9,235.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,285.12 / $4,161.14 / $9,855.36
| Facility | | $3,285.12 | $4,161.14 | $9,855.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,792.35 / $6,570.24 / $10,950.40
| Professional | | $2,792.35 | $6,570.24 | $10,950.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,299.58 / $3,285.12 / $7,939.04
| Professional | | $2,299.58 | $3,285.12 | $7,939.04 |